Neural mechanisms of hypnosis and meditation

Accepted Manuscript NEURAL MECHANISMS OF HYPNOSIS AND MEDITATION Giuseppe De Benedittis PII: DOI: Reference:

S0928-4257(15)00019-4 http://dx.doi.org/10.1016/j.jphysparis.2015.11.001 PHYSIO 624

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Journal of Physiology - Paris

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7 June 2015 18 August 2015 4 November 2015

Please cite this article as: Benedittis, G.D., NEURAL MECHANISMS OF HYPNOSIS AND MEDITATION, Journal of Physiology - Paris (2015), doi: http://dx.doi.org/10.1016/j.jphysparis.2015.11.001

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NEURAL MECHANISMS OF HYPNOSIS AND MEDITATION Giuseppe De Benedittis Interdepartmental Pain Center, Dept. of Pathophysiology and Transplants, University of Milan, Italy.

ABSTRACT Hypnosis has been an elusive concept for science for a long time. However, the explosive advances in neuroscience in the last few decades have provided a ”bridge of understanding” between classical neurophysiological studies and psychophysiological studies. These studies have shed new light on the neural basis of the hypnotic experience. Furthermore, an ambitious new area of research is focusing on mapping the core processes of psychotherapy and the neurobiology\ underlying them. Hypnosis research offers powerful techniques to isolate psychological processes in ways that allow their neural bases to be mapped. The Hypnotic Brain can serve as a way to tap neurocognitive questions and our cognitive assays can in turn shed new light on the neural bases of hypnosis. This cross-talk should enhance research and clinical applications. An increasing body of evidence provides insight in the neural mechanisms of the Meditative Brain. Discrete meditative styles are likely to target different neurodynamic patterns. Recent findings emphasize increased attentional resources activating the attentional and salience networks with coherent perception. Cognitive and emotional equanimity gives rise to an eudaimonic state, made of calm, resilience and stability, readines to express compassion and empathy, a main goal of Buddhist practices. Structural changes in gray matter of key areas of the brain involved in learning processes suggest that these skills can be learned through practice. Hypnosis and Meditation represent two important, historical and influential landmarks of Western and Eastern civilization and culture respectively. Neuroscience has beginning to provide a better understanding of the mechanisms of both Hypnotic and Meditative Brain, outlining similarities but also differences between the two states and processes.

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It is important not to view either the Eastern or the Western system as superior to the other. Cross-fertilization of the ancient Eastern meditation techniques presented with Western modern clinical hypnosis will hopefully result in each enriching the other.

MECHANISMS OH HYPNOSIS INTRODUCTION

Hypnosis has long been an elusive concept for science due to the lack of objective neurobiological markers of the state of trance, but the relentless advances in neuroscience in the last few decades (largely due to the introduction and refinement of sophisticated electrophysiological and neuroimaging techniques) have opened up a ‘bridge of knowledge’ between the classic neurophysiological studies and psychophysiological studies of cognitive, emotional, and sensory systems (De Benedittis, 2003). This is the foundation of neurophenomenology (Varela, 1996). While recent advances in neuroscience have undoubtedly contributed to unravelling the Veil of Maya of the Hypnotic Brain—that is its neurocognitive structure (De Benedittis, 2006)—hypnosis is also increasingly being recognized by the international scientific community as a valid and flexible physiological tool to explore the central and peripheral nervous system. This seems to be a real Copernican revolution in the field (De Benedittis, 2004). Current hypnosis research focuses on two major areas (De Benedittis, 2012) (Fig. 1): (a) intrinsic research, that is the research line concerned with the functional anatomy of hypnosis per se, in the absence of specific suggestions, the so-called ‘neutral hypnosis’ or ‘default hypnosis’, and the neurophysiological mechanisms underlying the hypnotic experience in dynamic conditions, and (b) instrumental research (or extrinsic studies), the use of hypnosis and suggestion for studying a wide range of cognitive and emotional processes as well as for creating ‘virtual analogues’ of neurological and psychopathological conditions in order to elucidate their underpinnings and eventually positively change the way we treat them. INTRINSIC STUDIES

An important fallout of neuroscience research concerns the precise status of hypnosis: discrete state of consciousness or process? Reality or hoax?

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For a long time hypnosis has been the subject of a quarrel between the dominant ‘credulous’ view (i.e., those claiming hypnosis is an ‘altered state of consciousness’) and the ‘sceptical’ view (i.e., those challenging the existence of hypnosis condition, based on the lack of objective indicators of trance and the reproducibility of hypnotic effects in a waking state through appropriate ‘motivating suggestions’) (Barber, 1969). This axiological uncertainty has been widely and definitively overcome by a growing body of convergent neurophysiological research—namely electrophysiology and neuroimaging - contributing to significant advances in our knowledge of hypnotic phenomena, including functional neuroanatomy of neutral hypnosis. These include electrophysiological studies (e.g., bispectral analysis), neuroimaging (e.g., single-photon emission computed tomography (SPECT), functional magnetic resonance imaging (fMRI), positron emission tomography (PET) ), advanced neuroimaging (e.g., real-time fMRI and brain-computer interface), and neurofeedback (De Benedittis, 2012). EEG Studies Hypnotic states and hypnotic responding (including hypnotic analgesia) are associated more often by increase in theta and gamma activity, with higher levels of theta tending to be associated with higher hypnotizability and hypnotic responding. ( Ray, 1997 ;Williams and Gruzelier, 2001; Jensen et al., 2015 ). These findings, particularly relating to gamma activity, show an overall inconsistency in the research studies (De Pascalis, 2007). Neuroscience has not only contributed to validating and defining the state of trance; it has also enabled us to differentiate between altered states of consciousness and ordinary states of consciousness. Bispectral electroencephalographic analysis, a sophisticated and complex evolution of spectral analysis, has proved to be effective in differentiating between subjects awake and subjects in trance on the basis of the bispectral (BIS) index (De Benedittis, 2008). Bispectral analysis utilizes a composite of multiple advanced electroencephalography (EEG) signal processing techniques, including bispectral analysis, power spectral analysis, and time domain analysis. It is a robust aid in monitoring the hypnotic effect of anaesthetics and has emerged as an important tool for anaesthesia management. The BIS index reflects the level of conscious sedation and/or loss of consciousness in patients undergoing general anaesthesia. The BIS Index is a number between 0 and 100 that correlates with important endpoints during administration of anaesthetic agents. BIS values near 100 represent a fully awake clinical state, while BIS value near 0 represent isoelectric EEG or cerebral death. When the BIS index value decreases below 80 the probability of explicit recall decreases dramatically. At a BIS index of

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less than 60, a patient has a very low probability of consciousness (i.e. , anaesthetized subject). Bispectral analysis and the BIS index can reliably measure and monitor the depth of hypnotic trance, thus distinguishing the ‘hypnotic zone’ quantitatively and qualitatively from different levels and states of consciousness. The “Hypnotic Zone” BIS index ranges between 77 and 92 (De Benedittis, 2008), with a subject within this BIS index range likely to be into hypnotic trance. For the first time the state of trance can be identified by an objective and reliable (electrophysiological) marker, as compared with the inadequate phenomenological (experiential) and behavioural (measurement scales of hypnotic depth) data of the past (De Benedittis, 2008). In a more recent study (Hinterberger et al., 2011), detectability of electrophysiological state changes during a hypnotic session as a correlate to the instructions was reported in one highly susceptible subject, with significant and congruent state changes occurring synchronously with specific induction instructions. There was also a highly significant increase in broadband activity during the stepwise trance induction that may point to a deep hypnotic state. Neuroimaging Studies Several neuroimaging (fMRI, PET) studies (Maquet, 1999; Faymonville et al., 2000; Rainville et al., 2002; Egner et al., 2005; Cojan et al., 2009; Del Casale et al., 2012) have contributed to creating a map of Regions of Interest (ROI) in the brain during ‘neutral’ or ‘default’ hypnosis (i.e., hypnosis in the absence of any specific suggestion), including the occipital cortex (involved in visualization processing, which is so important for the induction and the experience of hypnosis), thalamus, anterior cingulate cortex (ACC), inferior parietal cortex, precuneus (that normally mediates imagery and self-awareness) (Cojan et al., 2009), and dorsolateral prefrontal cortex. Perhaps we are not far from being able to draw a ‘Neurosignature’ (functional neuroanatomy) of hypnosis. Moreover, neuroimaging findings suggest a potential anatomical (morphological and volumetric) basis for hypnotizability, linking variations in the rostrum of corpus callosum to differences in attentional and inhibitory processes (Horton et al., 2004). In a more recent study (Hoeft et al., 2012), high-compared to low-hypnotizable individuals showed greater functional connectivity between left dorsolateral prefrontal cortex (DLPFC), an executive-control region of the brain, and the salience network composed of the dorsal anterior cingulate cortex (dACC), anterior insula, amygdala, and ventral striatum, involved in detecting, integrating, and filtering relevant somatic, autonomic, and

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emotional information. These results have provided novel evidence that altered functional connectivity in DLPFC and dACC may underlie hypnotizability. Conclusions Despite an increasing body of evidence suggesting a rather discrete Neuromatrix for the hypnotic state and process, hypnosis and hypnotic responses are probably best explained by more comprehensive models that take into account factors from biological, psychological, and social domains (Biopsychosocial Model) (Jensen et al., 2015). Recent findings provide preliminary evidence regarding the variables that remain viable as factors that might facilitate hypnotic responses; that is, structural connectivity, hemisphere asymmetry, higher levels of theta bandwidth activity, expectancies, trait hypnotizability, motivation, absorptive capacity, rapport, and context (Jensen et al., 2015). The role and the interactions of thes variables however remain to be elucidated. Hypnotic Analgesia A second fruitful area of intrinsic research has enabled a better understanding of the multidimensional neural mechanisms underlying hypnotic processes and responses—hypnotic analgesia (Jensen, 2008). One of the oldest medical applications of hypnosis concerns the control of pain, whose effectiveness, known for some time, has only recently found indisputable confirmation at the level of evidence-based medicine in published meta-analyses of randomized controlled studies in both acute and chronic pain (see review in De Benedittis, 2003; 2004). Hypnotic analgesia represents a significant paradigm of how neurophysiological and neuropsychological research has contributed decisively to a better understanding of the mechanisms of multidimensional pain control in trance. Since pain has a multidimensional structure involving sensory-discriminative, motivational-affective, and evaluative (attentional) aspects (Melzack and Casey, 1968), it is likely that hypnotic analgesia involves multiple mechanisms of pain modulation.

Supraspinal Central Nechanisms One possible explanation for the increased analgesic efficacy of

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hypnosis in highly hypnotizable subjects as compared with the low hypnotizables is related to greater cognitive flexibility (i.e. , the ability to adaptively modify cognitive strategies and awareness) (Crawford and Gruzelier, 1992; Crawford, 1994). In addition, highly hypnotizable subjects possess stronger attentional filtering capabilities and expression of fronto-limbic attentional activities. This allows the subject in trance to be more effective in refocusing their attention and diverting attention away from nociceptive or undesirable stimuli, as well as ignoring irrelevant environmental stimuli (Crawford, 1994). Cognitive control processes are associated with a supervisory attentional system (SAS), whose activity involves fronto-temporal cortical structures (Shallice, 1988). Neuroimaging techniques have contributed in a decisive way to revealing the putative mechanisms of cognitive modulation of pain, including hypnotic analgesia. In a pioneering study using SPECT, De Benedittis and Longostrevi (1988) reported a significant decrease of the regional cerebral blood flow (rCBF) in the primary sensorimotor cortex (S1) during suggestions of hypnotic analgesia in highly hypnotizable subjects only, possibly associated with a selective neural inhibition. But the turning point in neuroimaging studies of hypnotic analgesia was determined by the pivotal studies of a Canadian team headed by Pierre using PET. In the first of these studies (Rainville et al., 1997), it was shown that hypnotic manipulation of the degree of negative affective resonance (unpleasantness) evoked by a nociceptive stimulation in a group of volunteers concomitantly induced corresponding changes in the activities of the brain structures (i.e., increased/reduced activation of the ACC) involved in coding the motivational-affective component of pain. No change was observed in the activity of the primary sensorimotor cortex (S1) involved in processing the sensory-discriminative component of the nociceptive stimulus (Rainville et al., 1999a; 1999b). The extraordinary selectivity of hypnotic suggestion to manipulate differentially the two main components of the painful experience was documented by a striking linear correlation between the intensity of negative affective resonance, as suggested in hypnosis, and the level of activation of the ACC. This pioneering study was followed by others of the same group and by Belgian researchers (Faymonville et al., 2000; Hofbauer et al., 2001), which confirmed and extended the results of the aforementioned study, suggesting that the ability of hypnosis in differentially modulating the different aspects of pain perception is not rigid, structural, and unidirectional, but dynamic and dependent upon the structure and formulation of hypnotic suggestions.

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A more recent review of functional neuroimaging studies on pain perception under hypnosis (Del Casale et al., 2015) indicates that hypnosis-induced modifications of pain perception are related to functional changes in several ROI’s, including not only the cingulate (mainly ACC), but also the prefrontal, insular and pregenual cortices, the thalamus and the striatum. The ACC seems to be the key target in reducing pain perception, whatever the nociceptive stimulus applied, emphasizing its critical role in hypnosis-induced modification of sensory, affective, behavioral and cognitive aspects of nociception. Contrary to what had been previously believed (De Benedittis et al., 1989; Hilgard and Hilgard, 1994), it is becoming increasingly clear that hypnosis can modulate effectively not only the motivational-affective component of pain but also the sensory-discriminative one (more directly linked to the intensity of the nociceptive stimulation), albeit to a lesser extent. These findings confirm the great cognitive-perceptual flexibility mediated by trance and will certainly exert a significant impact in the clinical context. Taken together, these data support the notion that cognitive (hypnotic) modulation of pain alter dramatically the cortical Pain Matrix. The hypnotic modulation of pain intensity produces changes in pain related activity mainly in the primary somatosensory cortex (S1), while modulation of pain unpleasantness induces changes mainly in the anterior cingulate cortex (ACC), with the anterior (mid)cingulate cortex possibly modulating both sensory and affect components of pain. (Faymonville et al., 2000; Peyron et al., 2002). Spinal Mechanisms Hypnotic analgesia may also depend on the activation of descending inhibitory systems that specifically modulate the spinal transmission of the nociceptive input. The involvement of these systems during hypnotic suggestions of analgesia has been demonstrated by electrophysiological studies that have documented that hypnosis significantly reduces the amplitude of the nociceptive flexion reflex (R-III), believed to be linearly related to the intensity of perceived pain (Kiernan et al., 1995; Danziger et al., 1998) and the effect was proportional to the level of hypnotic suggestibility.

Autonomic and Peripheral Mechanisms

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In addition to the spinal and supraspinal mechanisms, there is increasing evidence that hypnosis also modulates the activity of the autonomic nervous system (ANS) and possibly the peripheral nervous system (PNS). The sympatho-vagal interaction of ANS during trance was analysed for the first time with spectral analysis of the heart rate variability signal (RR interval) by De Benedittis and colleagues (1994). The study showed that hypnosis modulates the RR interval by shifting the balance of sympato-vagal interaction towards an increased parasympathetic output, concomitant with a reduction in the sympathetic tone. The effect is positively correlated with hypnotic susceptibility. Though it has been shown (Langlade et al., 2002) that the heat pain threshold assessed by thermal stimuli is significantly elevated during hypnosis, suggesting that hypnosis can down-regulate neuronal inflow from A delta and C fibres stimulation, this finding has been challenged by a recent study (Kramer et al., 2014) indicating that hypnosis without a specific analgesic suggestion has no influence on pain thresholds, independent of the modality that is the source of pain (thermal, mechanical, etc.). This suggests that hypnosis does not specifically affect one kind of peripheral afferent nerve fibre but has an impact on central processing of perception, possibly by distraction and/or modulation of the affective component of pain. Conclusions: recent studies on hypnotic analgesia are rather convergent and strongly support multiple, hierarchical pain control systems during hypnotic suggestions of analgesia at different levels and sites within the nervous system. At peripheral level, there is a controversial evidence that hypnosis may modulate nociceptive input by down-regulating A delta and C fibers stimulation (Langlade et al., 2002, Kramer et al., 2014), while it can significantly reduce the sympathetic arousal (De Benedittis et al., 1994), relevant for inducing and maintaining some chronic pain states. At spinal level, hypnosis is likely to activate descending inhibitory systems by reducing the nociceptive RIII reflex, parallel to self-reported pain reduction (Kiernan et al., 1995;

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Danziger et al., 1998). At supraspinal cortical level, neuroimaging and electrophysiological studies have shown that hypnotic suggestions of analgesia can modulate directly and selectively both sensory and affective dimensions of the pain perception (the latter being reduced significantly more than pain), thus confirming, at least partially, the neodissociation theory by Hilgard and Hilgard (1994). Moreover, highly hypnotizable subjects possess stronger attentional filtering abilities than do low hypnotizable subjects. This greater cognitive flexibility might result in better focusing and diverting attention from the nociceptive stimulus as well as better ignoring irrelevant stimuli in the environment. Cognitive control processes are associated with a “supervisory attentional system”, involving the far frontal limbic and temporal cortices (De Pascalis et al., 1999; Crawford, 2001). This complex network might represent the ‘Neurosignature’ of the hypnotic modulation of pain (De Benedittis, 2003). It is noteworthy that the structures involved in pain perception are the same as those involved in its cognitive, hypnotic modulation (Peyron et al., 2002), though the functional dynamics of these complex patterns remains to be further elucidated. Fig. 2 shows schematically the putative mechanisms of hypnotic analgesia. Neurochemical Correlates of Hypnosis Several observations indicate that hypnotic analgesia does not depend on endogenous opioid mechanisms. Different groups of investigators have failed to demonstrate a reversal of hypnotic analgesia with an opioids antagonist (naloxone) (Goldstein and Hilgard,1975; Spiegel and Albert, 1983) or significant changes in beta-endorphin plasma levels during hypnotic suggestions of analgesia (De Benedittis et al., 1989; Moret et al., 1991). On the contrary, the dopamine system, because of its involvement in attentional tasks, is a particularly likely candidate for hypnosis. Spiegel and King (1992) demonstrated a robust correlation between measured hypnotizability and levels of homovanillic acid, a dopamine metabolite, in the cerebrospinal fluid. The anterior cingulate and right frontal cortex are rich in dopaminergic neurons.The observed correlation between hypnotizability and CSF HVA further implicates specific involvement of the frontal lobes where the majority of dopaminergic pathways exist, followed by the basal ganglia.

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INSTRUMENTAL (EXTRINSIC) STUDIES

In addition to intrinsic research on hypnosis and its mechanisms, neuroscience research is beginning to consider and use hypnosis as an attractive, viable, and appropriate physiological tool to explore and modulate the cognitive and emotional determinants of complex human experiences. Neuroimaging techniques offer new opportunities to use hypnosis as a probe into brain mechanisms and as a means of studying hypnosis itself. Cognitive Modulation Hypnosis can be considered as a heuristic paradigm of cognitive modulation (De Benedittis, 2012). Potential domains of current and future research include: attentional processes, pain control, manipulation of mental images and perceptual processes, mnestic processes, exploration of conscious and unconscious processes, neurocognitive processes, and genetic determinants of hypnotic responsiveness. Visual and Auditory Perception In addition to pain perception, the ability of hypnotic suggestions to modulate other perceptions has been investigated in several neuroimaging studies. One study on hypnotic suggestions of auditory hallucinations (Szechtman et al., 1998) has shown that the brain areas activated are essentially the same during the actual perception of an auditory stimulus (albeit with a gradient of less intensity of activation). Similarly, Kosslyn and colleagues (2000) have shown that visual illusions under hypnosis activate visual associative areas similar to those activated when perceiving a real visual stimulus. These studies suggest that the line between real perception of a stimulus and distorted perception (i.e., illusion) or absence of a stimulus (i.e., hallucination) is more elusive than formely believed. Sensory Hallucinations Derbyshire and colleagues (2004) have used hypnotically suggested pain in normal pain-free individuals to create an unequivocal analogue of functional pain. They found that the hypnotic pain experience was associated with widespread activation in classic pain areas (thalamus, anterior cingulate cortex, insula, prefrontal cortex, and parietal cortex), similar to that seen with a comparable physically induced pain and proportionate to the level of subjective pain reported. Interestingly, this activation pattern was not seen when participants were asked to imagine the same pain experience. Motor Hallucinations

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Motor control hallucinations are common in schizophrenic, dissociative, and conversion disorders. Blakemore (2003) studied eight highly hypnotizable subjects using PET. Three experimental conditions were included in the study: active movement (AM), real-passive (RP), and hypnotic deluded passive movement (DP). Results showed an increased activity in the parietal cortex and cerebellum in the DP condition, with an activation pattern similar to that detected in the AM condition. Hypnosis and Attention Modern cognitive studies have suggested that attention is neither a property of a single brain area nor that of the entire brain. Attention can be viewed as involving a system of anatomical areas consisting of three more specialized networks. These networks carry out the functions of alerting, orienting, and executive control. Distinct brain areas mediate different attentional processes (Raz and Shapiro, 2002; De Benedittis, 2003). Neuroimaging studies suggest that discrete brain areas mediate specific attentional processes. In a study by Raz et al., (2002) the Stroop interference test was used to assess interference in cognitive attentional processes under hypnosis. In more complex tasks, highly hypnotizable subjects showed significantly shorter reaction times compared to low hypnotizable subjects, confirming a greater attention skill related to high hypnotic susceptibility. Hypnosis and Memory It is well known that hypnosis is effective in inducing post-hypnotic amnesia and modulating implicit and explicit mnestic content (Cox and Bryant, 2008). A neuroimaging study (Mendelsohn et al., 2008) has shown that the suppression of episodic memories in hypnosis (posthypnotic amnesia) is associated with changes in brain areas responsible for long-term recall (i.e., occipital cortex, temporal cortex, and prefrontal cortex). These data have been interpreted as evidence of an active inhibition of the processes of mnemonic recall. Hypnosis cannot only inhibit processes of mnemonic recall. There is evidence that high-imagery words can be better recalled when they were learned under hypnosis (Halsband, 2006). Encoding under hypnosis was associated with more pronounced bilateral activations in the occipital cortex and the prefrontal areas as compared to learning in the waking state. Experimental Neuropsychopathology and Neurodynamic Correlates of Therapeutic Techniques

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Experimental neuropsychopathology is aimed at elucidating the neurocognitive processes that contribute, in whole or in part, to the aetiology, exacerbation, or maintenance of abnormal behaviour (Zvolensky et al., 2001). Hypnotic suggestions can serve as an experimental tool for the creation of hypnotic clinical analogues (virtual patients) (Oakley and Halligan, 2009) of neurological or psychiatric diseases, in order to elucidate psychophysiopathological mechanisms and eventually being used appropriately in the therapeutic setting. The most fascinating and advanced frontier is represented by the use of hypnosis as a neuropsychobiological investigation tool in psychotherapy (e.g., assessing psychobiological correlates of experimental unconscious conflicts with electrophysiological and/or neuroimaging techniques). Hypnotic analogues of neurological and/or psychiatric conditions (virtual patients) An intriguing study by Halligan and colleagues (2000) generated a hypnotic analogue of conversion hysteria (i.e. limb paralysis) in a healthy subject and compared his fMRI with those from real patients with hysteria. The results were striking: in the virtual patient the same key targets were activated as those observed in real patients. The psychophysiological and behavioural changes observed during the recall of memories in patients who have suffered psychological trauma often resemble the phenomena observed in trance. Activation of identical brain structures has been observed in studies of strong emotional recall as well as in studies of neuroimaging in hypnosis: thalamus, hippocampus, amygdala, medial prefrontal cortex, anterior cingulate cortex (Vermetten and Bremner, 2004). Therefore, it is not unlikely that the neurodynamic circuits activated in the recall of traumatic memories in patients with post-traumatic stress disorder largely overlap with those observed in trance for the recovery of unconscious memories/conflicts. Hypnotic modulation of conflicts in the human brain Increasing evidence suggests that cognitive-emotional conflicts involve the activity of the ACC. Hypothesizing that such conflict reduction would be associated with decreased ACC activation, Raz and colleagues (2005) recently combined neuroimaging methods and studied highly and less hypnotizable participants both with and without a suggestion to interpret visual words (i.e. , Stroop interference test) as nonsense strings. The associated increase in ACC activity in the absence of compensatory changes in left frontal cortical areas has been interpreted as evidence that hypnosis acts to decouple the normal relationship between conflict monitoring and cognitive control.

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Hypnosis is no longer a matter of dispute and controversy in the international scientific community as it has not only been established as a viable, valid, and reliable intervention for controlling discrete clinical syndromes, but it has been eventually recognized as a real psychobiological state and process. Despite an increasing body of evidence suggesting a rather discrete Neuromatrix for the Hypnotic Brain, hypnotic states and processes are probably best explained by more comprehensive models that stem from biopsychosocial domains (Jensen et al., 2015). Mostly important, neuroscience research is beginning to consider and use hypnosis as a physiologically effective tool for studying the normal human brain and to investigate neurodynamic correlates of psychotherapy (De Benedittis, 2003; 2012). Also, hypnotic clinical analogues are increasingly serving as clinical simulations to investigate specific hypotheses concerning neuropsychopathological disorders. In conclusion, the most recent clinical-experimental paradigms have established the role of the Hypnotic Brain as a physiological probe to explore brain/mind mechanisms, producing, in turn, an important impact on the advances of our knowledge on the nature of trance. This seems to be a new callisthenics for the human brain/mind. MECHANISMS OF MEDITATIVE STATES INTRODUCTION

The word meditation (from latin meditatio) is used to describe states, processes and practices that self-regulate the body and mind, thereby affecting mental and physical events by engaging a specific attentional set. From ancient times, people have been fascinated by the wonder of their own mind and the experience of the surrounding universe. This pondering, about one’s being in reality, may have been the beginning of a meditative mind, and the origin of various philosophies and religions (Deshmuck, 2006).

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Yoga is a way of adaptive self-integration, being at peace with oneself and at home in the world. Self-integration results from constant selfawareness and letting go of irrelevant memories, imaginations and distractions. Such a person functions with a truly undistracted and serene mind. When the mind is undirected and assumes its original, unmodified state, the Self experiences itself. Yoga is a skillful quietening of a distracted and ruminative mind with a natural resolution of emotional conflicts, culminating in a truly peaceful and intuitive conscious state. Three essential steps of Yoga include (a) Dharana: conscious focusing of attention on an object, an activity, a thought or an ongoing experience; (b) Dhyana: continued, sustained dwelling of attention on the same experience; and (c) Samadhi: effortless, self-absorptive, and intuitive state of understanding and realization of one’s true nature or being. Meditation means awareness – to be aware of what you are doing, what you are thinking, what you are feeling, aware without any choice, to observe, to learn. Then there is freedom to see things as they actually are, without distortion (tathata or suchness in Buddhism). The mind becomes unconfused, clear, and sensitive. There is no actual division between the organism and the mind. The brain, the nervous system and the mind are all one, indivisible. Meditation really is also a complete emptying of the mind. Meditation is also an art of efficient and adaptive management of personal resources and energy with total engagement or disengagement. There is a natural sense of well-being with self-understanding, spontaneous joy (Ananda), serenity, freedom, and self-fulfillment. It is where the ultimate pursuit of happiness and search for meaning in life resolve. One realizes the truth of one’s being in harmony with nature and nature in oneself. This enlightening process is nonlinear and dynamic (Deshmuck, 2006). HISTORICAL BACKGROUND OF EASTERN MEDITATIVE TRADITIONS

Buddha‘s teachings on “mindfulness” identified it as a means of attaining enlightenment, specifically “for the overcoming of sorrow and distress, for the disappearance of pain and sadness (dukkha)” (Otani, 2003). That means passing out from this world of suffering (Samsara) to Nirvana. His teachings later spread to two parts of Asia: one, to Southeast Asia as the Theravada tradition, and the other to the Far East as the Mahayana tradition.

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Out of the Theravada tradition emerged two primary meditation techniques known as Samatha or Samadhi (“tranquil dwelling”) , Vipassana (“insight achieving”), respectively and Ton-Leng (Dalai Lama’s loving kindness meditation)(Bercholz and Kohn, 1993). Vipassana practices of meditation have been popularized in the U.S recently under the name of “mindfulness meditation” (e.g., Hanh, 1999; Kabat-Zinn, 1995). In the Mahayana school, Buddhism incorporated Chinese Taoism and eventually evolved into Ch’an, or better yet known as Zen in Japan. The term Zen is a translation of a Sanskrit term, Dhyana, the seventh highest state of consciousness immediately preceding Samadhi, the final and non-duality stage described in the eight limbs of Yoga (Bercholz and Kohn, 1993). NEUROPHENOMENOLOGY OF MEDITATION

Phenomenological descriptions of changing inner states (first-person data) can be strengthened by neurophysiological data. In consciousness studies, this has given rise to a new field called Neurophenomenology (Varela, 1996). Neurophenomenology integrates subjective experience and brain dynamics in the Neuroscience of Consciousness.The true neurophenomenological investigation would simultaneously measure subjective experience (experiential correlates), phenomenological correlates and neurophysiological correlates for the same time period or event. Now we can begin to define the state by using a combination of selfreport and neurological indicators. The state is suggested by a shift of brain activity taken together with a shift in phenomenological experiences in the direction described by people in deep hypnosis or meditation (Kumar, et al., 1996; Pekala and Kumar, 2000; Cardeña, 2005). EXPERIENTIAL CORRELATES

Eastern and Western meditation seems to have much in common. Given that regulation of attention is the central commonality across the many divergent methods (Davidson and Goleman, 1977), meditative styles can be usefully classified mainly into two types— concentrative and mindfulness—depending on how the attentional processes are directed. Most meditative techniques lie somewhere on a continuum between the poles of these two general methods (Shapiro and Walsh, 1984; Wallace, 1999; Andresen, 2000; Newberg and Iversen, 2003; Cahn and Polich, 2006).

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Concentrative or Ideative Meditation. The first form of meditation is more common in Western meditation (e.g., Loyola’s spiritual excercises or contempletions, but also in Hindu and Buddhist Theravada and Tantric Varayana tradition (e.g., Samadhi) . Concentration, or Samadhi in Pali (a dead language associated with ancient Buddhist texts), involves focusing attention on a particular object, such as breathing, a candle light, a face of the Buddha or symbolic object such as compassion, which may lead to a subjective experience of absorption with the object of focus (object meditation) (Newberg and Iversen, 2003; Deshmuck, 2006). It aims for serenity and leads to altered states of consciousness, called the Absorptions (Jhanas ), at least one of which resembles deep hypnosis (Holroyd, 2003). These altered states demonstrate cognitive, emotional, and motivational changes as they increase in depth (Bucknell, 1993). Like the attentional focus procedures in hypnosis, this kind of meditation emphasizes concentration and letting go of thoughts. Abstract or Non-Ideative Meditation (more common in Eastern meditation: Vipassana tradition and Mindfulness). Samadhi meditation is a precursor to Vipassana (Insight) meditation, which has been referred to as “choiceless awareness” (Krishnamurti, 1991) or “mindfulness” (Kabat-Zinn, 2005). This second form of meditation is one in which the subjects simply attempt to clear all thought from their sphere of attention and to reach a subjective state, characterized by a sense of no space, no time, and no thought (objectless meditation). This state is also fully integrated and unified, such that there is no sense of a self and other (Newberg and Iversen, 2003; Deshmuck, 2006). The practice of insight meditation (Sati) is based upon the Great Discourse on the Foundations of Mindfulness (Maha Satipatthana Sutta), which includes the contemplation of the body, the contemplation of the feelings, the contemplation of the mind, and the contemplation of the mental objects, through three stages: a) concentration (e.g., visual stimuli, breathing, mandala ); b) tranquillity ( the sound of silence) and c) insight (consciousness of consciousness or meta-consciousness: the void is form and the form is void; reality is impermanent). Fundamental to this mindfulness training is Anapanasati, which literally means “breath awareness” as taught by the Buddha himself.

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Mindfulness aims for insight (Vipassana ) through observation of one’s own mental processes and altered states of consciousness. Vipassana/Mindfulness (VM) meditation trains participants to observe the rapidly shifting panorama of sensations, thoughts, emotions, etc., and to describe mental activities and states in great detail and nonjudgmentally (Thoughts are only thoughts!)(Wallace, 1999; Shear and Jevning, 1999; Holroyd, 2003). Thus, VM requires becoming aware of all of one's senses and acknowledging any negative feelings, pain, or blockages in order to achieve equanimity. Equanimity is defined as not interfering with the flow of the senses at any level, including the level of preconscious processing (Young, 1994). It is noteworthy that meditative states cannot be maintained uninterruptedly for a long time and between two consecutive attentional acts there is an inter-attentional awareness, with no attended-attendee duality (Deshmuck, 2006; De Benedittis, 2015). This results in a refreshing experience of no experience, which is analogous to waking up from a sound, non-REM sleep with no dreams. This inter-attentional awareness can lead to a state of non-alertness or Turiya (Deshmuck, 2006) . During non-alertness conscious mentation exists only in a potential form. The enlightening process is nonlinear and dynamic, whereas the common state of self-consciousness functions within a chaotic attractor basin (Deshmuck, 2006). Fig. 3 shows eastern major meditative traditions and their experiential correlates. Mindfulness and Clinical Applications. Mindfulness meditation programs primary goal is to identify and reduce patients' suffering, both physical and emotional pain, developing detached observation and awareness of the contents of consciousness. It also has the potential for transforming the ways in which we respond to life events and for relapse prevention in affective disorders. Mindfulness-Based Stress Reduction (MBSR) interventions are being increasingly used for stress, psychological well being, coping with chronic illness (such as pain, skin disorders, etc.) as well as adjunctive treatments for psychiatric disorders (Kabat-Zinn, 2005; Chiesa and Serretti, 2010; Marchand, 2014). However, given the low-quality designs of current studies it is difficult to establish whether clinical outcomes are due to specific or non-specific effects of Mindfulness practice.

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Tong-Len. Another form of Buddhist meditation that has been popularized, particularly by the Dalai Lama (H. H. Dalai Lama and Cutler, 1998), is Tong-Len. It is a practice designed to cultivate lovingkindness by means of meditation. This practice resembles significantly the split-screen technique in hypnosis (Spiegel and Spiegel, 2004). It is said to be a powerful technique for the monk to develop compassion and empathy for others. Mixed forms (Ideative/Non-Ideative). These meditative techniques such as Rinzai and Soto tradition (e.g., koan) and Trascendental Meditation (MT) - lie somewhere on a continuum between the poles of the above mentioned general methods. NEURAL CORRELATES

Meditation states and traits are being explored with neuroelectric and neuroimaging methods. The findings are becoming more cohesive and directed, even though a comprehensive empirical and theoretical foundation is still emerging. CNS function is clearly affected by meditation, but the specific neural changes an differences among practices are far from clear. Neuroelectric (EEG & ERP) Studies Zen Meditation. In a classic study with a group of Soto Zen monks, Kasamatsu and Hirai (1966) reported distinct EEG changes during mindful Zen meditation. The experienced monks began to show alpha EEG in less than a minute after starting to meditate, and this effect lasted for some time even after the session was over. Concentrative Meditation. Bispectral electroencephalographic analysis has proved to be effective in differentiating between subjects awake and subjects in trance on the basis of the bispectral (BIS) index (De Benedittis, 2006). The same technique has been used in a most recent study on three concentrative (Samadhi) lama meditators (De Benedittis, 2015). A significant reduction of the BIS-Index was found, as compared with waking subjects, but only during the attentional act period (approx. 15’).

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Concentrative Meditation vs Mindfulness. Electroencephalographic recordings in 10 Subjects were used to differentiate among two forms of meditation, concentration and mindfulness, and a normal relaxation control condition. Significant differences were obtained between concentration and mindfulness states at all bandwidths. Results suggest that concentration and mindfulness "meditations" may be unique forms of consciousness and are not merely degrees of a state of relaxation (Dunn et al., 1999). Tong-Len (Loving-Kindness Meditation). In a study using a Tibetan Buddhist monk highly trained in tong-len visualization, significant increases in 40Hz gamma activity in the left middle frontal gyrus were found, suggestive of left-sided anterior activation, a pattern previously associated with positive affect (emotional happiness), in the meditators compared with the non-meditators (Davidson et al., 2003). Lutz and colleagues (2004) studied eight long-term Tibetan Buddhist meditators who had engaged in contemplative practice for periods of time ranging from 15 to 40 years, with anywhere from approximately 10,000 to 50,000 hours logged in meditation. A control group consisted of 10 students averaging 20 years of age, each of whom had only ten hours of training in meditation. 
 All meditators exhibited atypically large amounts of synchronized gamma activity 5 to 15 seconds after beginning the meditation, with significant asymmetrical gamma synchrony appearing in the left midfrontal areas. Analysis revealed that the longterm meditators showed greater such synchrony than controls, as well as higher baseline levels of gamma activity. Comparing different meditative states. Recently, Lehmann et al. (2012) looked at EEG-patterns in experienced meditators of different traditions (Tibetan Buddhists, QiGong, Sahaja Yoga, Ananda Marga Yoga and Zen). When going into and out of meditation, significantly different connectivities revealed different topographies in the delta frequency band and in the beta-2 band. EEG-patterns showed lower coherence during meditation in all five traditions. The globally reduced functional interdependence between brain regions in meditation suggests that interaction between the self-process functions is minimized, and that constraints on the self-process by other processes are minimized, thereby leading to the subjective experience of non-involvement, detachment and letting go, as well as of all-oneness and dissolution of ego borders during meditation.

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EEG Studies: Conclusions and Clinical Implications Electroencephalographic (EEG) studies have revealed a significant increase in alpha and theta activity during meditation (Chiesa and Serretti, 2010), concomitant with an overall slowing of consciousness processes (De Benedittis, 2015). Increase in alpha and theta wave activity is believed to be indicative of states of inner calm and stability (Siegel, 2007). The increased gamma wave synchrony generated during Tibetan Buddhist loving kindness meditation has been repeatedly observed as active in attention and perception, and implicated in associative learning. It has been theorized that gamma wave synchrony may play a significant role in binding the disparate information conveyed by the central nervous system into coherent perception (Singer, 2001).
 
 If gamma wave synchrony does in fact play a significant role in perception, this could explain why long-term practitioners of loving kindness meditation exhibit a readiness and willingness to compassionately respond to the interior experience - both positive and negative - of others. In other words, attentional training with compassionate embrace as its focus seems to develop the brain's capacity for unifying sensory information into coherent patterns of perception that support both personal and interpersonal connection. According to Lutz and co-workers (2004), attention and affective processes, which gamma-band EEG synchronization may reflect, are flexible skills that can be trained .This readiness to readily and practically express compassion has always been the main objective for such Buddhist practices. Urry and colleagues (2004) correlated left prefrontal asymmetry, as evidenced in both the mindfulness and loving kindness forms of meditation, with eudaimonic well-being, defined by Siegel (2007) as enveloping "the psychological qualities of autonomy, mastery of the environment, positive relationships, personal growth, self-acceptance, and meaning and purpose in life" . This left anterior activity has also been correlated with resilience, the capacity to rebound after particularly negative experiences (Davidson, et al., 2003). ERP Meditation Studies. Sensory EP (Evoked Potentials) and cognitive ERP (Event Related Potentials) meditation assessments have produced a variety of effects (see review in Cahn and Polich, 2006). The major difficulties in many studies are a lack of methodological sophistication, no replication of critical conditions, and inconsistency of task and study populations. Some intriguing hints of meditation changing early cortical auditory processing appear reliable, with suggestions that P300 also can be affected by meditation practice. Simple CNV (Contingent Negative Variation) tasks yield an increase in amplitude for both state and trait effects of meditation, such that CNV effects may reflect changes in attentional resource allocation.

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Neuroelectric Studies: General Conclusions . It is difficult to draw specific inferences from these studies .The current review of meditation states and traits indicates considerable discrepancy among results, a fact most likely related to the lack of standardized designs for assessing meditation effects across studies, the variegated practices assayed, and a lack of technical expertise applied in some of the early studies. EEG meditation studies have produced some consistency, with power increases in theta and alpha bands and overall frequency slowing generally found. Additional findings of increased power coherence and gamma band effects with meditation are starting to emerge. ERP meditation studies are sparse but suggest increased attentional resources and stimulus processing speed or efficiency. Neuroimaging Studies Early studies. Early neuroimaging studies on relaxation practice and meditation provide the first evidence of functional brain changes using or C during a relaxation practice and a meditative practice, respectively. oga idr , literally “ oga- leep,” is a state in the oga tradition where consciousness of the world and consciousness of action are meant to be dissociated the mind “withdraws” from wishing to act and is not associated with emotions or the power of will. study of blood flow changes during oga idr practice was carried out by (199 and colleagues (1999). During all meditative phases, overall increases in bilateral hippocampus, parietal, and occipital sensory and association regions were found compared to control conditions. This pattern suggests an increase of activity in areas involved in imagery. Deactivation was found during meditation in orbitofrontal, dorsolateral prefrontal, anterior cingulate cortices, temporal and inferior parietal lobes, caudate, thalamus, pons, and cerebellum. This differential activity was interpreted as reflecting a “tonic” activity during normal consciousness in baseline condition. The areas decreasing during the meditation state are known to participate in executive function or control of attention. The AA. interpreted these results as reflecting dissociation between two complementary aspects of consciousness: the conscious experience of the sensory world and the “fact or illusion of voluntary control, with self regulation”.

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Using SPECT, Newberg et al. (2001) measured changes in regional blow flow (rCBF) while 8 relatively experienced Tibetan Buddhist practitioners meditated. In constrast to Lou et al. (1999), Newberg and colleagues reported an increase in orbital frontal cortex, dorsolateral prefrontal cortex (DLPFC) and thalamus. They also found a negative correlation between the DLPFC and the superior parietal lobe which was interpreted as reflecting an altered sense of space experienced during meditation. The difference in the frontal areas between their finding and that of Lou et al. (1999), was viewed as reflecting a difference between an active and a passive form of meditation. fMRI Studies. Concentrative ( Ideative) Meditation (Samadhi). Lazar

et al. (2000) used functional MRI to identify the ROI’s that are active during a simple form of meditation (Focused Attention /Mindfulness-Awareness meditation
 : a form of Kundalini Yoga) and relaxation response. A significant increase of activity was observed in the dorsolateral prefrontal and parietal cortices, hippocampus, temporal lobe, anterior cingulate, striatum, and pre- and postcentral gyri during meditation. The results indicate that the practice of meditation activates neural structures involved in attention and control of the autonomic nervous system. The comparison of early versus late meditation states showed activity increase in these regions, but within a greater area and with larger signal changes later in the practice. Because the pattern of brain activity increased with meditation time, it may index the gradual changes induced by meditation. In eight Tibetan Buddhist monks, voluntary meditation with sustained attention was initially accompanied by activation in bilateral, but right more than left, prefrontal cortex and cingulate gyrus (Newberg and Iversen, 2003). he perception of one’s bodily self depends on the activation of posterior, superior parietal lobules. The hippocampus acts to modulate cortical arousal and responsiveness via connections with the prefrontal cortex, amygdala, and hypothalamus. These structures are involved in generating attention, emotion, and imagery.

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Another attention-related study (Brefczynski-Lewis et al., 2004) studied experienced Buddhist meditators (> 10,000 hours of cumulative meditation practice) and newly trained control subjects while they performed a Focused Attention meditation, alternating with a passive state, while undergoing fMRI. fMRI of concentration meditation in both the experienced meditators and the controls showed common areas of activation in the traditional attention network, including areas such as the intraparietal sulci, thalamus, insula, lateral occipital, and basal ganglia. However, experienced meditators showed more activation, especially in the frontal-parietal network. The increased activation in these regions for experienced practitioners may represent a neural correlate for these subjects' expertise in sustained attention. Non-Ideative Vipassana/Mindfulness Meditation. A review of this literature (Marchand, 2014) revealed compelling evidence that mindfulness impacts the function of the medial cortex and associated default mode network as well as insula and amygdala. Additionally, mindfulness practice appears to activate the prefrontal cortex (PFC) , the anterior cingulate cortex (ACC) (Chiesa and Serretti, 2010). Structural imaging studies are consistent with these findings and also indicate changes in the hippocampus. Long-term meditation practice is associated with an enhancement of cerebral areas related to attention.

Meditation and Cortical Thickness (Neuroplasticity). Magnetic resonance imaging was used to assess cortical thickness in 20 participants with Mindfulness experience (Lazar et al., 2005). Brain regions associated with attention, interoception and sensory processing (thus important for sensory, cognitive and emotional processing) were thicker in meditation participants than matched controls, including the prefrontal cortex and right anterior insula. Between-group differences in prefrontal cortical thickness were most pronounced in older participants, suggesting that meditation might slow age-related cortical thinning. These data provide the first structural evidence for experience-dependent cortical plasticity associated with meditation practice.

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Mindfulness Therapeutic Interventions and Cortical Thickness (Neuroplasticity). Therapeutic interventions that incorporate training in mindfulness meditation have become increasingly popular, but to date little is known about neural mechanisms associated with these interventions. In a recent, controlled longitudinal study to investigate prepost changes in brain gray matter concentration attributable to participation in a Mindfulness-Based Stress Reduction (MBSR) program (Hölzel et al., 2011), anatomical magnetic resonance (MRI) confirmed increases in gray matter concentration within the left hippocampus. Whole brain analyses identified increases in the posterior cingulate cortex, the temporo-parietal junction, and the cerebellum in the MBSR group compared with the controls. The results suggest that participation in MBSR is associated with changes in gray matter concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing, and perspective taking. Pure compassion and loving-kindness meditation
 (Ton Leng): the role of compassion/empathy. Using fMRI, Lutz et al. (2008) assessed brain activity while novice and long-term practitioners generated a lovingkindness-compassion meditation, alternating with a resting state. During the meditative state, a common activation in the striatum, anterior insula, somato-sensory cortex, anterior cingulate cortex and left-prefontal cortex was found, concomitant with a deactivation in the right interior parietal. This pattern was robustly modulated by the degree of expertise, with the adepts showing considerably more enhanced activation in this network compared with the novices. These results support the role of the limbic circuitry in emotion sharing. In addition, data provide evidence that this altruistic state involved a specific matrix of brain regions that are commonly linked to feeling states, planning of movements and positive emotions. Finally, love and compassion require an understanding of the feelings of others; hence, a common view is that the very regions subserving one’s own feeling states also instantiate one’s empathic experience of other’s feelings. he key proposal is that the observation and imagination of another person in a particular emotional state automatically activates a similar affective state in the observer, with its associated autonomic and somatic responses, suggesting a sort of embodied simulation-driven mirror-neurons mechanism (Gallese, 2009). Neuroimaging Studies: Conclusions. Recent structural and functional neuroimaging studies are beginning to elucidate neural processes associated with the practice of meditation. These studies demonstrate some consistency of localization for meditation practices. Meditation techniques that target specific underlying processes are thus likely to engage different neural circuitry.

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Although there is considerable potential for advancement in neuroscience through neuroimaging studies of meditation, the number of published studies remains sparse and anecdotal, and current results have to be considered with caution (Chiesa, 2010). Further research is needed to answer critical questions about replications, self-selection, placebo, and long-term effects of meditative states. CONCLUSIONS

An increasing body of evidence provides insight in the neural mechanisms of the Meditative Brain. Despite over 50 years of research in this field, no clear neurophysiological signatures of discrete meditative states have been found. Much of this failure can be attributed to the narrow range of variables examined in most meditation studies, with the focus being restricted to a search for correlations between neurophysiological measures and particular practices, without documenting the content and context of these practices (Thomas and Cohen, 2014). More meaningful results could be obtained by expanding the methodological paradigm to include multiple domains such as the cultural setting (“the place”), the life situation of the meditator (“the person”), details of the particular meditation practice (‘the practice’), and the state of consciousness of the meditator (“the phenomenology”). Discrete meditative styles are likely to target different neurodynamic patterns. Recent findings emphasize increased attentional resources activating the attentional and salience networks with coherent perception. Cognitive and emotional equanimity gives rise to an eudaimonic state, made of calm, resilience and stability, readines to express compassion and empathy, a main goal of Buddhist practices. Structural changes in gray matter of key targets, such as hippocampus, involved in learning processes, suggest that these skills can be learned through practice. Functional and structural changes are strongly modulated by the degree of expertise with long-term meditators showing more activation than novice meditators in crucial ROI’s. HYPNOSIS vs MEDITATIVE STATES: SIMILARITIES and DIFFERENCES SIMILARITIES BETWEEN HYPNOSIS AND MEDITATION

Experiential Correlates

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Eastern meditation seems to have much in common with hypnosis. For example, they both require mental concentration and receptivity on the part of the practitioner (Brown and Fromm, 1986; Carrington, 1993; Otani, 2003). Absorption (Tellegen and Atkinson, 1974) also seems to play a critical role in meditation and hypnosis alike. Hypnosis and concentrative (object) meditation are similar in the attentional and concentration practices employed that result in altered states of consciousness; in the phenomenology of those altered states; and in the neurophysiology associated with those states. Taken together, from a neurophenomenological point of view Hypnosis and Samadhi are closely linked. These similarities challenge the current belief that hypnosis was “discovered” in eighteenth century Europe when Mesmer first introduced animal magnetism. Rather, it is far more accurate to view hypnosis as having its roots in Buddhist (and probably other religious) meditation that predates Mesmerism by at least two millennia (Holroyd, 2003). Both concentration and mindfulness are familiar and crucial elements in hypnosis. Brown and Fromm (1986) elucidate that hypnotic trance is not only characterized by “concentrated and focused attention” but also by “ego-receptivity.” Current research shows that high hypnotic suggestibility may be a multifaceted construct, one that needs to account for those who primarily use focused attention (concentration) as well as those who rely on fantasy absorption (mindfulness)( Holroyd (2003). Attentional and Concentration Practices. Both hypnosis and meditation begin with attempts to relax and concentrate the mind by focusing attention. Meditators today most commonly focus on the breath. In hypnosis focusing and sustaining attention might mean staring at a spot, watching a swinging pendulum, or focusing on a symbolic object (such as compassion). The process used to reach the state has been described in the hypnosis literature as dis-attending to competing stimuli (Crawford, 1994). In the meditation literature, it has been described as letting go of thoughts and perceptions (Khema, 1997). Focusing and sustaining attention in both hypnosis and meditation leads to similar changes in mental state. Two experiments give relevant information. High hypnotizables were studied in one experiment (Cardeña, 2005); Indian Kundalini-Yoga (a mixed, active-passive form of meditation) meditators in the other (Venkatesh et al., 1997). Both used the Phenomenology of Consciousness Inventory (PCI) (Pekala, 1991).

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Both meditation and deep self-hypnosis were associated with elevations on PCI scales reflecting alterations in state of awareness, selfawareness, time sense, perception, and meaning; with changes in imagery vividness and rationality and both processes were accompanied by feelings of joy and love. In hypnosis, attention moved from a focus on imagination at medium levels to free floating in deep self-hypnosis. Again, meditation showed similar changes. Neural Correlates of Hypnosis and Meditation: Similarities and Differences EEG Studies. Considering hypnosis research first, high band theta is related to hypnotizability, and theta power often increases as people go into deep hypnosis. This has been extensively reviewed and summarized by a number of authors (Crawford and Gruzelier,1992; Ray, 1997; Crawford, 2001). The increased theta power is found in various cortical areas, but the far frontal area is well represented. The far frontal cortex and the anterior cingulate gyrus on the midline surface of the frontal lobe are areas where theta figures prominently in meditation studies (Cahn and Polich, 2006). Halsband et al. (2009) compared EEG changes in brain activity during hypnosis and Tibetan Buddhist meditation, reporting high amplitudes in alpha frequency bands most pronounced with meditation at frontal positions and with hypnosis in central and temporal locations. Significantly greater activity in theta 2 band was observed only with hypnosis in both hemispheres. Neuroimaging Studies. In both the meditation and hypnosis investigations, areas where theta is prominent (frontal cortex and especially anterior cingulate cortex) are also perfused with blood, which means that they are working hard. Two meditation investigations and four hypnosis investigations show increased regional blood flow to these areas (see review in Holroyd, 2003). More recent neuroimaging studies using PET and fMRI (Halsband et al., 2009) showed differential plasticity changes in brain connectivity in hypnosis and meditation.

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Neurophenomenology of Hypnosis and Meditation: Conclusions. To summarize, both concentrative meditation and deep hypnosis result in similar psychological changes, such as diminished thought, emotional reaction, and body sensations, with consequent equanimity, peacefulness, and absorption. There is also a sense of unity with all or a sense of merging. Both hypnosis and meditation altered state experiences are accompanied by neurophysiological changes, particularly in frontal areas and anterior cingulate cortex, with slowing and coherence in cortical areas representing choice and executive control. However, due to some phenomenological differences between hypnosis and meditation, it is not surprising to find differential brain plasticity changes (Halsband et al., 2009). DIFFERENCES BETWEEN HYPNOSIS AND MEDITATION

The differences between hypnosis and meditation have to do largely with goals and expectancies, as well as their relative emphasis on suggestion (hypnosis) or mindfulness (meditation). Also, hypnosis (usually) calls for two people and meditation is a solo experience. Differences in Goals and Practices. The treatment principles, goals, and focuses differ radically between the two paradigms as well. In the Eastern model, the primary focus of healing is preventive in nature and the goal is to restore the balance of the “mind/body” through continuous care (Holroyd, 2003). Meditators are interested in life-long goals having to do with serenity, insight, and spiritual liberation or enlightenment. In the West, however, search for healing can better be explained in terms of medical system. It often means repair or cure in reaction to illnesses or injuries. Its main goal is to control both external and internal environment in order to achieve or restore optimal health. People seeking hypnosis are generally interested in a specific outcome such as symptom removal. As for the duration of treatment, the Western medical system tends to be pragmatic, often business-oriented, relatively short-term and most effective in the management of acute illnesses and injuries. The Eastern model, on the other hand, holds a long-term, if not life-long, perspective. As such, it is not particularly suited for injuries or infections but may be more efficacious in the handling of chronic ailments. Hypnosis patients rarely practice the skill in the long run. On the contrary, meditators expect to spend years developing their skill. They practice daily for 20 minutes to an hour, and go away for retreats where they practice 10 to 15 hours a day for weeks or months.

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However recent cross-fertilization of Eastern meditative techniques presented with Western modern clinical hypnosis has softened these differences in goals and practice, with an increasing number of subjects practicing self-hypnosis for long periods of time and meditative techniques (e.g., Mindfulness-Based Stress Reduction, MBSR) increasingly used for medical treatment. Expectancy and Suggestion. Suggestions are generally given in hypnosis but not in meditation. eople doing meditation don’t expect suggestibility but rather expect that their “pure bright awareness” will enable them to see reality without bias of prior conditioning or emotion. Tab. I shows comparison between hypnosis and meditation. GENERAL CONCLUSIONS Hypnosis and Meditation represent two important, historical and influential landmarks of Western and Eastern civilization and culture respectively. Neuroscience has beginning to shed a new light on the mechanisms of the Hypnotic and Meditative Brain, outlining similarities but also differences between the two states and processes. It is important not to view either the Eastern or the Western system as superior to the other (Otani, 2003). The recent introduction and popularization of meditative techniques (e.g., Mindfulness) in the West raise some important issues. Since in the West we live in a profoundly non-monastic and non-contemplative society, to adopt these profound and esoteric contemplative practices and the monastic way of life without sufficient context remains highly problematic (Wallace, 2001). In our Western consumer society, business oriented, the dominant medical paradigm prioritizes profit, efficiency and short-term therapies. Can we assume that meditative practices known to be effective in Eastern cultures and contexts, and transplanted in Europe or America in the same format and with no adaptation for the West, do still work ? How can be sure that the Dharma scene in the Buddhist world may be our own unique staircase to Heaven ? So simply dropping the teachings into a cultural tabula rasa, is not reasonable and even desirable. We might expect that degenerating Buddhism practices run the danger of losing their uniqueness in the West and being totally assimilated into a naive and regressive New Age culture. But we also can change the problem in an opportunity. We probably need to adapt and transform these practices into a idiosyncratic Western way. One solution is a close, respectful, and open-minded dialog between Western disciples and Buddhist adepts.

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This cross-fertilization of the ancient Eastern meditation techniques presented with Western modern clinical hypnosis will hopefully result in each enriching the other.

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FIGURE CAPTIONS Fig. 1. Potential domains of the Hypnotic Brain. Intrinsic research is the research line concerned with functional anatomy of hypnosis per se, in the absence of specific suggestions, the so called “neutral hypnosis” or “default hypnosis”, and the neurophysiological mechanisms underlying the hypnotic experience in dynamic conditions. Instrumental research (extrinsic studies) refers to the use of hypnosis and suggestion for studying a wide range of cognitive and emotional processes as well as for creating “virtual analogues” of neurological and psychopathological conditions in order to elucidate their underpinnings and eventually positively change the way we treat them. Legend: A.S.C., altered states of consciousness; O.S.C., ordinary states of consciousness. Fig. 2. Putative Mechanisms of Hypnotic Analgesia (De Benedittis, 2003). Fig. 3. Eastern Major Meditative Traditions and Their Experiential Determinants.

Tab. I. Comparison between Hypnosis and Meditation: Similarities and Differences.

38

Legend: +, positive association; -, negative association; ?, unconclusive, controversial or no data.

39

40

41

EASTERN MEDITATIVE TRADITIONS

THERAVADA

MAHAYANA

Samadhi

Concentrative Object Meditation

Vipassana Mindfulness

Abstract Objectless Meditation

Tong-Len

Loving-kindness Meditation

Taoism Zen

Table(s)

HYPNOSIS

MEDITATION

EXPERIENTIAL DETERMINANTS Altered State of Consciousness Concentration/Focused Attention Receptivity/Absorption Hypnotizability Suggestion Insight/Mindfullness

+ + + + + -

+ + + ? +

+ +

+ +

+ + + +

+ + ? ?

+ -

+ + (Long-Term)

NEURAL DETERMINANTS Brain States Theta Activity Gamma Activity Neuroimaging ROI’s ACC Frontal Precuneus Occipital Functional Connectivity Structural Connectivity PSYCHOSOCIAL DETERMINANTS Expectancies Goals Set

Medically oriented: Healing Pure Bright Awareness (Enlightenment) Repair Restore Usually call for two A solo

Average Duration

Rapport Short

Long-life